According to international convention, PAD includes euthanasia and physician-assisted suicide. Both are voluntary, requested forms of medicalised killings — in the former, a physician injects the patient with lethal drugs, whereas in the latter the patient self-administers such drugs. PAD looks very different depending on which normative ethical theory one takes as one’s point of departure. It is shown how various theories can be used to either reject or defend PAD. Furthermore, this lecture demonstrates that very many of the arguments for PAD would also justify the controversial practice called LAWER; i.e. medical murder.

Terminal sedation (TS) may be described as the most radical or extreme version of palliative sedation (PS). In its new, 2014 guidelines on PS, the Norwegian Medical Association (NMA) provides the following definition: «By palliative sedation is meant pharmacological depression of the level of consciousness in order to alleviate suffering that cannot be relieved in any other way.» TS involves the deepest form of such pharmacological depression, and the patient is normally kept in a state of total unconsciousness until death occurs – hence I have in an article in Lancet Oncology in 2009, with Swiss physician and bioethicist Georg Bosshard as co-author, called TS «deep and continuous palliative sedation» (DCPS). In this lecture, I address three issues that make DCPS particularly challenging ethically and clinically: First, that it entails the destruction of patient autonomy; second, that the treatment strategy might have a life-shortening effect; and third, that the indication for DCPS is a controversial matter indeed. As regards the second issue, many guidelines on PS state that it should only be given to patients with a life expectancy of a few days or up to 1-2 weeks at most. However, the NMA states that PS «shall normally» be given only that close to death, and accordingly the treatment may be extended beyond the final phase – with an increased risk that the patient may die from complications or adverse effects associated with the treatment. When it comes to the grounds for initiating PS, the NMA hold that «mental symptoms alone are only in rare cases an indication for palliative sedation.» I discuss whether or not existential suffering may be considered as a mental «symptom».ESPMH conference on Facebook.

Euthanasia – that is, drug-induced, medicalized killing by a doctor of a patient upon his voluntary and competent request – is legal according to statute in the Netherlands, Belgium and Luxembourg. The Netherlands has practiced euthanasia since 1973; however, it was only formally legalized in 2002 when a new law entered into force. From that year onwards, not only do doctors have an exclusive right to perform euthanasia; patients have a corresponding right to ask for it. Still doctors are under no legal obligation to do so; they may opt out, and refer a patient to another doctor who might be willing to comply with the patient’s request. There is thus a right to ask for euthanasia but no right to get it. Yet in practice it happens that doctors experience pressure coming from both patients and their next of kin; after 2002, apparently some patients behave as if they do indeed have a right that euthanasia be performed. Besides being a practical-clinical conflict, this is to a large extent an ethical conflict as well: Doctors may be reluctant to kill the patient for moral reasons, the main argument being that it goes against everything they have been thought in medical school – i.e., that their role is to preserve life, not to take it. Seriously ill patients, on the other hand, may perceive life as of no value anymore, thus believing they are «better off dead» by means of euthanasia. Also in cases of non-treatment decisions (NTDs) – that is, withholding or withdrawing life-sustaining treatment – there is potential for conflicts. It is at the discretion of a doctor to determine whether there is indication for treatment. For example, he might see, or judge, treatment in a particular case as futile. But the patient might disagree violently and may, in contradistinction to in euthanasia, value life so highly that he thinks he is clearly «better off alive» no matter how small chances are that e.g. resuscitation following cardiac arrest would be successful. Accordingly, some (like patients with advanced metastatic cancer) do want futile treatment – even though there is no right to such. «Futility» is a notoriously difficult concept both clinically an ethically, notwithstanding the fact that occasionally there are clear-cut, paradigmatic instances of what it would mean. These kinds of conflicts are regularly framed in terms of patient autonomy. The present paper is equally focussed on doctor autonomy, an issue that has been given much less attention than it deserves.

Abstract: Research has demonstrated that patients request E/PAS for a number of reasons, and that a «request» is not always that. On the contrary, it may be an expression of something else. Hence there exist various strategies for dealing with patients who air thoughts about wanting to die, including treatment of depression and psycho-social support. Together these may be coined «negative» responses since they all attempt to avoid premature death. This presentation addresses none of these; instead, it deals with the «positive», or affirmative, response that consists in complying with a request. The performing of E/PAS is now an option within certain palliative care services in Belgium – called the «integral» model. This model is rejected, both clinically and ethically. Furthermore, the idea of «palliative futility» upon which it is based is shown to be devoid of meaning. In countries where E and/or PAS is legal, palliative care providers should refrain from engaging in these activities if they are to remain true to the practice and values of palliative care.

«Deep and permanent sedation until death: ethical challenges». Topical Seminar: Is palliative sedation an option for intractable pain – therapeutic and ethical aspects. The European Federation of Chapters of the International Association for the Study of Pain (EFIC) 6th triennial congress, «Pain in Europe VI», Lisbon, Portugal, 9-12 September 2009.

Abstract: In its most radical form, palliative sedation in given in such a way that the patient dies without regaining consciousness. This gives rise to a number of ethical issues, including: Is such radical sedation justified when the main indication is refractory psychological or existential suffering? Normally, deep and permanent sedation is thought to be a proportionate response in cases of intolerable pain and for other physical symptoms that are unresponsive to conventional therapies. But even then certain difficult issues remain: can the treatment be clearly distinguished form euthanasia? If yes, how? If no, why not? May euthanasia be seen as a preferable alternative to it? Even though the patient is alive when unconscious until death, has one not at least «killed» the person he used to be, as well as having destroyed his autonomy and taken away his quality of life? Tentative answers to all of these topics are presented.

«Justice» & «Autonomy». An updated research agenda on ethics in palliative care: starting from the four ‘principles' of health care ethics. 3rd Research Forum of the European Association for Palliative Care (EAPC): 'Methodology for Palliative Care Research'. Stresa, Italy, 3-6 June, 2004.